Medication Summary

The inflammatory activity in the anterior chamber is generally mild and can fluctuate over time. With minimal inflammation in an asymptomatic patient, chronic use of topical steroids is not indicated. However, FHI can be associated with pain, floaters, increased anterior segment inflammation, and elevated intraocular pressures. These cases may warrant short-term treatment with a topical corticosteroid.^[2]

Class Summary

Corticosteroids have anti-inflammatory properties and cause profound and varied metabolic effects; they modify the body's immune response to diverse stimuli.

Prednisolone acetate suspension 1% (Pred Forte)

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Generic preparations may be significantly less potent because of markedly larger particle sizes, approximately 10 µm in diameter. The larger particles decrease the effective exposure of drug to ocular surfaces, reducing absorption and potency. Rebounds may occur when switching from proprietary to generic prednisolone acetate 1% suspension on a dose-for-dose basis.

Initial dosage is titrated according to the degree of inflammation, and the therapeutic goal is to reduce the inflammation to the level prior to the flare-up.

Drops should be spaced at least 5 min apart to avoid dilution effects. Gentle eyelid closure or punctal occlusion can significantly decrease upper airway irritation and systemic absorption. A second drop given immediately after the initial drop does not increase potency because the conjunctival cul-de-sac only holds about 10 microliters, and each drop contains 40 microliters.

Class Summary

Nonsteroidal anti-inflammatory drugs (NSAIDs) have analgesic, anti-inflammatory, and antipyretic effects. Their mechanism of action is not known but may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms also may exist, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions.

Topical formulations provide reasonable anti-inflammatory therapeutic effect without the major adverse effects of steroids. Although very potent analgesics, NSAID drops are generally far less potent than steroids.

Diclofenac ophthalmic (Voltaren)

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Inhibits prostaglandin synthesis by decreasing activity of enzyme cyclooxygenase, which, in turn, decreases formation of prostaglandin precursors. May facilitate outflow of aqueous humor and decrease vascular permeability.

Ketorolac ophthalmic (Acular)

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Inhibits prostaglandin synthesis by decreasing activity of the enzyme cyclooxygenase, resulting in decreased formation of prostaglandin precursors, which, in turn, results in reduced inflammation.

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Author

Manolette R Roque, MD, MBA, FPAO Section Chief, Cataract and Refractive Surgery, Department of Ophthalmology, Asian Hospital and Medical Center; Section Chief, Ocular Immunology and Uveitis, International Eye Institute, St Luke's Medical Center Global City

Manolette R Roque, MD, MBA, FPAO is a member of the following medical societies: American Academy of Ophthalmology, American Uveitis Society, European Society of Cataract and Refractive Surgery, International Ocular Inflammation Society, Philippine Academy of Ophthalmology, Philippine College of Surgeons, Philippine Medical Association, Philippine Ocular Inflammation Society, Philippine Society of Cataract and Refractive Surgery, University of the Philippines Medical Alumni Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Simon K Law, MD, PharmD Clinical Professor of Health Sciences, Department of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, American Glaucoma Society

Disclosure: Nothing to disclose.

R Christopher Walton, MD Adjunct Professor, Department of Ophthalmology, University of Texas Health Science Center at San Antonio

R Christopher Walton, MD is a member of the following medical societies: American Academy of Ophthalmology, American Uveitis Society

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy, Sr, MD † Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy, Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

John D Sheppard, Jr, MD, MMSc Professor of Ophthalmology, Microbiology and Molecular Biology, Clinical Director, Thomas R Lee Center for Ocular Pharmacology, Ophthalmology Residency Research Program Director, Eastern Virginia Medical School; President, Virginia Eye Consultants

John D Sheppard, Jr, MD, MMSc is a member of the following medical societies: American Academy of Ophthalmology, American Society for Microbiology, American Society of Cataract and Refractive Surgery, American Uveitis Society, Association for Research in Vision and Ophthalmology

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: 1-800-DOCTORS; AbbVie; Alcon; Aldeyra; Allergan; Alphaeon; ArcScan; Baush+Lomb; Bio-Tissue; Clearside; EyeGate; Hovione; Mededicus; NovaBay; Omeros; Pentavision; Portage; Santen; Science Based Health; Senju; Shire; Sun Pharma; TearLab;TearScience;Topivert<br/>Serve(d) as a speaker or a member of a speakers bureau for: AbbVie; Alcon; Allergan; Bausch+Lomb; Bio-tissue; EyeGate;Hovione;LayerBio; NovaBay;Omeros;Portage; Santen; Shire; Stemnion; Sun Pharma;TearLab;TearScience; Topivert <br/>Received research grant from: Alcon; Aldeyra; allergan; Baush+ Lomb; EyeGate; Hovione; Kala; Ocular Therapeutix;Pfizer; RPS; Santen;Senju;Shire;Topcon; Xoma.

C Stephen Foster, MD, FACS, FACR, FAAO, FARVO Clinical Professor of Ophthalmology, Harvard Medical School; Consulting Staff, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary; Founder and President, Ocular Immunology and Uveitis Foundation, Massachusetts Eye Research and Surgery Institution

C Stephen Foster, MD, FACS, FACR, FAAO, FARVO is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Association of Immunologists, American College of Rheumatology, American College of Surgeons, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, American Uveitis Society, Association for Research in Vision and Ophthalmology, Massachusetts Medical Society, Royal Society of Medicine, Sigma Xi, The Scientific Research Honor Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Aldeyra Therapeutics (Lexington, MA); Bausch & Lomb Surgical, Inc (Rancho Cucamonga, CA); Eyegate Pharma (Waltham, MA); Novartis (Cambridge, MA); pSivida (Watertown, MA); Xoma (Berkeley, CA); Allakos (Redwood City, CA)<br/>Serve(d) as a speaker or a member of a speakers bureau for: Alcon (Geneva, Switzerland); Allergan (Dublin, Ireland); Mallinckrodt (Staines-upon-Thames, United Kingdom)<br/>Received research grant from: Alcon; Aldeyra Therapeutics; Allakos Pharmaceuticals; Allergan; Bausch & Lomb; Clearside Biomedical; Dompé pharmaceutical; Eyegate Pharma; Mallinckrodt pharmaceuticals; Novartis; pSivida; Santen; Aciont.

Ira G Wong, MD, MS Clinical Professor, Departments of Ophthalmology, University of California at San Francisco and Stanford University School of Medicine; The Francis I Proctor Foundation for Research in Ophthalmology, University of California at San Francisco

Ira G Wong, MD, MS is a member of the following medical societies: American Academy of Ophthalmology

Disclosure: Nothing to disclose.

Mansoor Arif, MD Hospitalist, Department of Medicine, Mount Auburn Hospital; Instructor, Department of Medicine, Harvard Medical School

Mansoor Arif, MD is a member of the following medical societies: American College of Physicians, Massachusetts Medical Society

Disclosure: Nothing to disclose.

Neerav Neel Lamba, MD, MBA Fellow in Ocular Immunology, Massachusetts Eye Research and Surgery Institution

Neerav Neel Lamba, MD, MBA is a member of the following medical societies: American Academy of Ophthalmology

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the assistance of Ryan I Huffman, MD, with the literature review and referencing for this article.